Was that a glint in his eye or not? Either way, he had a point – to a point.

There’s limited evidence of female domination in the higher echelons of the healthcare profession, i.e. medical anaesthesia. The road through medical school to specialization is male-dominated, and although there are two female residents in the current first year cohort of the anaesthesia programme at CHUK no women have graduated since it launched in 2006.

Professor Angela Enright with the two female trainees at the CHUK anaesthesia programme

But the anaesthesia technician profession is different.

All techs graduate from the same three-year programme at the Kigali Health Institute (KHI), which was set up in direct response to the crisis-point shortage of healthcare workers in Rwanda.

They are trained in the practicalities of anaesthesia, and only the essentials of physiology necessary for the job at hand. KHI has trained about 30 anaesthesia technicians a year since the programme began in 1996, and there are now about 160 working in Rwanda. Although the medical anaesthesia programme is no longer nascent, techs far outstrip the number of medical graduates at present.

Practicing patient resuscitation at the SAFE course

So their responsibilities are vast. Techs look after the operating rooms; they do emergency resuscitation (trauma, shock, cardiac arrest). In rural areas, they can end up with cases even more complicated than a medical anaesthetist at a teaching hospital would be faced with, alone.

And because applicants must have completed a science qualification to be eligible for the programme, with the majority coming from nursing, demographics mean that a high proportion of techs are women.

“I had to work all hours!” explained Jeanette Kayitesi, an anaesthesia tech in Kigali, reminiscing about her first job in a small city hospital where she was the only anaesthesia technician. “They always came to get me. They came to get me in the middle of the night. They came to get me on maternity leave…”

Domination? Maybe not. But it’s certainly a dramatic change from the position of women in Rwanda a generation ago.

La DOMINATION at the SAFE course

“In the past, they didn’t like it when a married woman kept working,” explained Mediatrice Usabye, an education director from southern Rwanda, who was in Rwamagana for a conference.

“People saw a woman as someone to marry, to raise children; if a family had a boy and a girl, the boy was the one who went to school.

“But after the genocide the government realized there was a disparity between male/female education, and a gender imbalance in all domains. Now things are changing. They’re working to close the gap. Women have paid maternity leave (one month in the private sector; three months in the public sector).”

Today, the rector of KHI is a woman.

Dr Chantal Kabagabo, Rector of the Kigali Health Institute

So is the anaesthesia department head at the National University of Rwanda.

That doesn’t change the fact that the reason women appear to ‘dominate’ in anaesthesia, sir, is partly because they are encouraged to train as nurses, not doctors.

“You may ask me why that is,” said Mediatrice, imposingly. “It’s because so many books are written in Rwanda, especially in primary studies…they show pictures. Pictures of women as nurses and teachers.”

Anaesthesia providers pose outside the operating theatres at CHUK

But Rwandan women are writing their own stories long after they finish primary school. Take Jeanette. She recently finished her Masters in Public Health (MPH), and wouldn’t be satisfied, she explained, if she didn’t keep learning and working. She likes her job as an anaesthesia tech because her day is never the same twice.

She also has five children, aged between 12 and three.

At first her husband nagged when she carried on working after they were married, after their children were born. Why did she have to take further studies? Why couldn’t she stay home with the kids?

And now?

The magnificent Jeanette

“He’s so proud. Now when we’re out, I hear him on the other side of the room, telling strangers about my job. Well, he says, my wife…”

Talk to Félicité Mukeshimana. She’s an anaesthesia technician at a district hospital in Ruhango, a province in the south of Rwanda.

Félicité and Fiona in their finery

Félicité has two daughters – the first aged five, and the second, Fiona, two-months old and of course still nursing. Nursing before the morning lecture. Nursing at lunchtime. Nursing in the evening during the dinner ceremony to celebrate the end of the first SAFE course last week.

They traveled together more than 100 miles by winding road from home to Rwamagana, Félicité in front and Fiona in back, surveying the world from her tightly bound sling.

“It’s important for us to be together and its important for me to be on the course,” Félicité explained, settling in to nurse.

They’re not the only traveling duo. Several mothers and babies have checked in over the last ten days, and several pregnant women too.

Consolee, an anaesthesia technician from Kibagabaga Hospital is glowing! But a four-day intensive training course is hardly putting your feet up

Félicité is the only person at her hospital with formal training in delivering anaesthesia. There are some nurses who have learned how to step in at a pinch, but as the technician, Félicité ultimately bears responsibility for anaesthetizing, resuscitating and relieving pain for every single patient that comes to the door.

There are about 160 anaesthesia technicians in Rwanda, graduates of a three year training programme. Medical anaesthetists are far fewer, and mainly to be found in the teaching hospitals and urban areas. Technicians generally go to work in the rural hospitals, where they may be the only trained anaesthesia provider in the district.

They’re seeing late-presenting, complex cases, and these in droves – 38,000 emergency c-sections in 2011 and climbing. Obstetrics is the single biggest caseload, and inevitably presents the bulk of complications.

The traditional guheka style of carrying babies is both practical and snug as a bug in a rug

Continuing education is essential. But education opportunities for anaesthesia technicians in Rwanda come around every – come to think of it, when was the last time you saw a blue moon?

And if a basic training course is rare, an opportunity like the SAFE Course and Lifebox training – four intensive days of practical work and relevant theory, addressing every possible complication, crisis and skill required to deliver safer obstetric anaesthesia, not to mention the distribution of essential equipment and CPD credits – well that’s never happened here before.

With all the logistics, time and financial support required, it’s not immediately clear when it will happen next.

So Félicité and her colleagues don’t have much choice: if they attend the training, their babies are coming too.

“I was a hospital nurse, but I trained as an anaesthesia technician so that I could help the surgeon to keep the patient safe, without pain,” Félicité told us, rocking the bundle in her arms. “I wanted to reduce pain.”

Speechless.

Her daughter has the most perfect little rosebud baby mouth, and it’s mewling softly. She’s been so quite all day, but she’s tired, she’s hungry, and it’s late.

The SAFE course is too good an opportunity to miss – but you know, we know, Félicité knows – good grief, it really isn’t easy.

Did you know that in 2006 the Rwandan government banned plastic bags in the capital city of Kigali?

(Spot the rookie at the airport, sheepishly jettisoning contraband.)

Today the grass, unpocked with litter, is buena vista green. Thanks to the civic and environmental efforts of the last few years, Kigali is one of the cleanest cities you could hope to visit.

Another fact about Rwanda in 2006: did you know that at the time there was just one single medical anaesthetist, Dr. Jeanne D’Arc Uwambazimana, in the entire country?

Today, there are 20.

Thanks to a collaborative, empathetic and energetic partnership between the National University of Rwanda (NUR), the Kigali Health Institute (KHI) and the Canadian Anesthesiologists’ Society International Education Foundation (CAS IEF), an anaesthesia residency programme was set up. The Rwanda Society of Anaesthesiologists (RSA) has now been formally acknowledged by the government as an official organization, with an important role to play in the ongoing improvement of Rwandan healthcare.

Anaesthesia residents are training in Rwanda for the first time

Such dramatic changes, in such a short amount of time – it’s easy to invest them with symbolism. A city in healing from the appalling atrocities that took over its streets; a profession long-marginalized that has raised its profile twenty-fold.

But forget symbolism and consider practical impact: this beautiful city that people are pleased and proud to live in; those countless lives that have been saved through increased access to safe anaesthesia.

Certainly surgery is still a critical healthcare concern in Rwanda, but it’s a damn sight better than it was ten years ago. And it’s against this optimistic background that #SAFERwanda came to town!

There are so many exceptional organizations and individuals involved in delivering this rigorous programme, that they really need their own background stories told.

Drs Patty Livingstone, left, and Faye Evans, right (who you might remember from her role in the Georgia Society of Anesthesiologists’ runaway-success Make It 0campaign for Lifebox) have been blogging about their work in getting the SAFE Course up and running in Rwanda since they arrived in the country several weeks ago.

It’s a great behind-the-scenes insight into hosting a course like this. (Step one: begin more than a year ago.)

Week one participants at the SAFE Course in Rwamagana

But the whirlwind really picked up speed (cc: “The Calm Before the Storm“) last Monday, with the arrival of 55 anaesthesia techs, residents and consultants from 13 district hospitals across the country.

…and 90 Lifebox pulse oximeters, part of an incredible 250 units donated by members of CAS to Rwanda. That’s enough oximeter for distribution to every single operating room and recovery setting at the district hospitals currently delivering surgery without this essential monitoring.

The second group of anaesthesia providers began arriving last night, fired up by reports from their friends who attended last week. (“Not boring!” – what higher praise?)

It’s exciting to think about the first group, back at work and scattered around the country.

This morning they’re checking their anaesthetic machines and charging their pulse oximeters. Hopefully they feel a little more prepared for whatever obstetric emergency rolls through the door next, and energized to know that their colleagues in anaesthesia worldwide are proud to stand with them – in symbol, and in practice.

No need to be witty when you’re one of the greatest surgical priorities for healthcare in low-resource settings. An emergency c-section is the most common major procedure in Sub-Saharan Africa: in Rwanda, for example, 2011 saw more than 38,000 urgently undertaken, as opposed to less than 2000 planned.

Safely deliver a struggling baby from a mother, locked in obstructed labour for days and deadly weary, and with one operation you’ve pulled two lives back from certain brink.

Safe delivery at the Good News Hospital in Madagascar

But those are the good stories – the truth is, carrying a baby to term and making it to the door of a hospital is still no guarantee of safe delivery. Lack of resources, training and support can make surgery in low-resource settings dangerous, particularly in the rural areas – and that’s before you factor in complex resuscitations, post partum haemorrhage, and conditions far more advanced than would ever be seen in a hospital in a high-resource setting.

Simply put, the operation that should save the mother and baby may become the very thing that needlessly ends it.

Neonatal monitoring at the University Teaching Hospital of Kigali, Rwanda

Today marks another landmark on the road to changing this reality.

In Rwamangana, Rwanda, more than 60 anaesthesia providers have just finished the first day’s sessions – this very minute, in fact (the Lifebox blog has never felt so live!) – of day 1 at the SAFE Obstetrical Anaesthesia course.

Led by faculty from the Rwanda Society of Anesthetists (RSA) and the Canadian Anesthesiologists’ Society International Education Foundation (CAS IEF), the course is supported by the Rwanda Ministry of Health and the World Federation of Societies of Anaesthesiologists (WFSA). It is designed to make a long term impact on the safety and quality of obstetric anaesthesia care.

Over the next few days attendees will develop their skills in obstetric anaesthesia, everything from routine procedures to resuscitation and crisis management.

They’ll flex and strengthen their capacity for teamwork in the operating room through the ‘Building SAFE Teams’ curriculum – confident communication and teamwork being essential for a safe OR, as we well know from the WHO Surgical Safety Checklist.

They’ll get training in how to use Gradian Health Systems’ Universal Anaesthesia Machine (UAM), which is specially designed for use in low-resource settings by a team that knows the importance of safe anaesthesia in safe obstetric care (see Gradian’s recent post on the subject at Every Mother Counts).

And they’ll leave with Lifebox pulse oximeters – enough, in fact, for every OR in the whole country! Last year CAS led a Make It 0 campaign that succeeded beyond our wildest dreams (combined and totaled). They raised funds for more than 250 oximeters for Rwanda, and we’ll be distributing them at the training course this week.

That’s right – we!Lifebox is thrilled to be joining the team, and over the next few weeks we’ll be sharing photos, tweets (#SAFERwanda), blog posts and more. The course repeats next week with another group of anaesthesia providers – so stand by…

If you’ve seen our excitement on Facebook or watched us struggle to contain our characters on Twitter, you’ll know that we’ve got some big news to share.

Our colleagues in Papua New Guinea have heard the news.

The British Medical Journal, one of the most prestigious peer-reviewed medical journals in the U.K., has – well – we’ll let them tell you:

“Christmas is coming and this week we launch the BMJ’s Christmas appeal,” explained editor Fiona Godlee in her recent editorial.

“After last year’s success, when BMJ readers gave over £33, 632 to buy 210 pulse oximeters for use in 10 low resource countries, we are supporting the Lifebox Foundation again.”

Well!

We’re excited to have a second introduction to the BMJ readership, and thrilled at the opportunity to update those readers whose generosity allowed us to do so much more over the last 12 months.

And so we interrupt your regularly scheduled Lifebox broadcast for a foreign holiday of sorts: feature articles, blog posts and Q&As hosted on the BMJ website. We’ll introduce you to colleagues worldwide whose work on the frontline of the surgical safety crisis has been supported by BMJ readers, and to the educators, donors and hands down champions we are working with to make surgery safer.

Click on over with us to read more about how Lifebox is working to support the rebuilding of surgical capacity in Rwanda following the genocide, what it feels like to be a house officer at a hospital in Tanzania, and how your support is helping to take away the terrible, answerless questions faced by anaesthesia providers in Ethiopia.

BMJ oximeters were part of a large shipment we sent to Togo last month, and the pictures from the workshop came back just this week. 113 monitors were distributed and 179 anaesthesia providers were trained by the Association National des Techniciens en Anesthesie du Togo (ANTART). Look at what you helped to make happen! And imagine how much more we can do.

Monday morning we were happy to see our our old friend Dr Rebecca Jacob, newest president of the Indian Association of Pediatric Anesthesiologists, heading across the red carpet. She brought along the WFSA paediatric committee to say hi (and give a high-drama demonstration of the oximeter!).

They reminded us about how important it is to have a neonatal probe for sats monitoring of the smallest patients, and they’re right – so we’re reminding you in turn that Lifebox offers a neonatal wrap probe for just US$25 (no shipping fee, when you buy at the same time as the oximeter).

Hot to follow was Dr Mwumvanera Theoneste, an anesthesiologist from Kigali University Teaching Hospital (CHUK) in Rwanda.

“In my first year, when I was a resident, I had a case – a small child – and the tube became disconnected,” he told us, weighing the Lifebox oximeter in his hand. “You will find out, but later…too late. When the brain is deprived of oxygen for three minutes – it’s a catastrophe. It’s death.”

Dr Theoneste is working with our colleagues at Harvard and the Canadian Anesthesiologists’ Society on a long-term project to deliver oximeters and WHO Surgical Safety Checklist training across the country. It’s a vital, multi-partner undertaking that we’re thrilled to be a part of, and we’ll keep you updated as the year progresses.

Doctors - no strangers to cafeteria planning

Another project we’re excited to tell you about has been brewing cross-continent since the American Society of Anaesthesiologists conference in Chicago last year. When the Department of Anesthesiology at the University of Florida presented a (giant!) cheque for $33,700 for Lifebox, we took a gameshow-style photo and then got down to business.

Dr Kayser Enneking, head of the U of F department and Dr Carolina Haylock-Loor, president of the Sociedad Hondurea de Anestesiologia, Reanimacion y Dolor (SHARD) met at the WCA this week for the first time. In an English and Spanish medley, we put plans in motion for a training workshop later this year.

Another project we’re excited to tell you about – and another – will have to wait until after lunch.